=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023507837
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HUGH MICHAEL KELLY LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2018
-----------------------------------------------------
Last Update Date | 05/07/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 TROY RD
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04929-3015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-217-0340
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 35
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04929-0035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-217-0340
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LC15379
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------